Failure to Develop Comprehensive Care Plans for Positioning and Mobility
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was developed and implemented for two residents concerning their positioning and mobility needs. Resident #16, who had a left hand contracture, did not have a care plan addressing this condition. Observations noted that the resident's left hand was consistently clenched in a fist, and interviews with staff confirmed awareness of the contracture but revealed that no care plan had been created to address it. The Registered Nurse Unit Manager acknowledged the absence of a contracture care plan and admitted that one should have been written. Resident #60, who used a specialized tilt-in-space wheelchair, also lacked a comprehensive care plan for positioning. Observations showed the resident in various states of improper positioning, such as leaning to one side with their head unsupported and feet dangling without footrests. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, indicated a lack of awareness and specific instructions regarding the use of the specialized wheelchair. The Director of Rehabilitation and the Director of Nursing both stated that the care plan should have included detailed instructions for the wheelchair's use, but no such documentation was found. The deficiency was further highlighted by the absence of documented education for direct care staff on the use of the tilt-in-space wheelchair. The Director of Rehabilitation mentioned that the Certified Nurse Aide Care Guide and a Positioning Care Plan should have provided necessary instructions, but these were not in place. The Registered Nurse Unit Manager admitted responsibility for developing and updating care plans and acknowledged the lack of a developed care plan for Resident #60's specific positioning needs.